Healthcare Provider Details

I. General information

NPI: 1699012245
Provider Name (Legal Business Name): NORTHERN NEW MEXICO COUNSELING SERVICES, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2013
Last Update Date: 07/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 OPPENHEIMER DR SUITE 200
LOS ALAMOS NM
87544-2384
US

IV. Provider business mailing address

555 OPPENHEIMER DR SUITE 200
LOS ALAMOS NM
87544-2384
US

V. Phone/Fax

Practice location:
  • Phone: 505-660-5726
  • Fax:
Mailing address:
  • Phone: 505-660-5726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-04885
License Number StateNM

VIII. Authorized Official

Name: MIRIAM THORP
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 505-660-5726